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The CQUIN Learning Network
Differentiated Service Delivery
for Urban Populations
May 2, 2018
CQUIN: Focusing on the “How”
of Differentiated Service Delivery
Exchange of Best Practices
and Lessons Learned
WEBSITE, WEBINARS, JOURNAL CLUBcquin.icap.columbia.edu
VIRTUAL COMMUNITIES OF PRACTICE
WORKSHOPS AND MEETINGS
Today’s Case Studies
CQUIN: The HIV Learning Network 4
South Africa: Shipping Container Solutions
Zambia: Urban Adherence Clubs
Malawi: Drop in Centers
Urban DSD
The CQUIN Learning Network 5
Urban DSD
Urban Differentiated Service Delivery
6The CQUIN Learning Network
Michael Odo, MBBCH, MSc, MPH, is the technical advisor for
HIV care and treatment for the Department of HIV/AIDS, at
the Malawi Ministry of Health. Dr. Odo will present on Drop-in
Centers for female sex workers in urban Malawi.
Phil Roberts, MBA, is the CCMDD project lead at Last Mile in
South Africa. Mr. Roberts will present on the shipping container
solution for chronic medicine pick up points in urban South
Africa.
Mpande Mukumbwa-Mwenechanya, BPharm, MClinPharm, is
the manager for the community ART for retention study at
the Centre For Infectious Diseases Research in Zambia (CIDRZ).
Ms. Mpande will present the CIDRZ urban adherence group (UAG)
model.
The CQUIN Learning NetworkDifferentiated Service Delivery for Urban Populations
A CQUIN Webinar
Key Population Services through Drop in Centres (DICs)
in MalawiMichael Odo; Rose Nyirenda
Ministry of Health, Lilongwe, Malawi
May 2, 2018
9.7%
2.4%
0.9%
0.3%0%
2%
4%
6%
8%
10%
12%
14%
2000 2005 2010 2015 2020
Adults 15+
Adults 15+ not yet diagnosed
Children
Children not yet diagnosed
HIV Prevalence: Malawi
62.7% among FSWs (2014)17.3% among MSMs and
27% among Prisoners
Mzuzu
Lilongwe
Mangochi
Machinga [DREAMS]
Zomba [DREAMS]
Blantyre
Geographical Scope: Six Districts
“Creation of and/or scale-up safe spaces/drop in centres….”- NSP 2015-2020
v
Framework for LINKAGES Cascade of
services and stakeholder coordination
Pakachere IHDC ● YONECO ● CEDEP
• District Health Offices (DHO)• Private clinics• Baylor Children’s Foundation
Ministry of Health ● National AIDS Commission ● DHA
• Central hospitals• DREAM Lab• Lighthouse
• PLACE study• Outreach teams
• Malawi Police Service• CHREA • Other legal and advocacy
partners
Service Delivery Modalities for KPs
• Outreach Clinics
• Drop-in Centers (DICs): combination of
services and safe space for KPs
• Hybrid: facilities where service provision largely
depend on other stakeholders (public and
private health facilities
• Static: LINKAGES-supported clinics which
provide services to KPs
Package of Services
All Key Populations
Clients of FSW• Prevention messages
• Condoms and lubricant
• HIV testing
• STI screening
• TB screening
• Reduction of stigma and discrimination
• GBV screening
• Violence/crisis response team
• Psychosocial counseling• Clinical, legal, and psychosocial referrals
• Data collection, collation and use
FSW only • Family planning services
• PMTCT
HIV Positive KP • Links to ART
• Links to VL testing
• Formation and functionality of KPLHIV support groups
Clinical Arm and Leadership of DIC
• Clinician/Nurse (who serves as DIC Manager and in
charge of catchment area of a group of hotspots)
• The DIC manager reports to District Coordinator
• HTS counselor
• Receptionist
Community arm of the DIC
• Peer educators (PE). Operate from hotspots, typical
ratio, 1 PE to 40 peers. Responsible for sensitization on
comprehensive package for HIV prevention care and
treatment including provision of condoms, lubes, TB
screening, referral for STI screening
• Peer navigators (PN). Also operate from individual
hotspots. Primarily responsible for supporting with
treatment adherence and retention alongside secondary
preventive package of services.
Cumulative FSW HIV Cascade – Unique FSW
Challenges and Successes
Acknowledgments
The CQUIN Learning NetworkDifferentiated Service Delivery for Urban Populations
A CQUIN Webinar
Shipping Container Solution for Chronic Medicine
Pick up Points in South AfricaPhil Roberts
Project Last Mile
May 2, 2018
Central Chronic Medicine Dispensing &
Distribution (CCMDD) Process
19The CQUIN Learning Network
CCMDD improves patient access to medicine through central dispensing &
distribution of medicines to patient convenient locations
Front View of Shipping Container Solution
20The CQUIN Learning Network
Internal View of Shipping Container Solution
21The CQUIN Learning Network
Introduction to Shipping Container Solution for
Chronic Medicine Pick up Points
• A private public partnership with a service provider, Project Last Mile (PLM) and National Department of Health (NDoH)
• A gap was identified in areas where there were a high number of Chronic patients registered on the CCMDD program but stuck in PHC facilities
• The proposed solution was placing a shipping container on a trial and validation basis
• These are self contained semi-mobile units to issue CCMDD Patient Medicine Parcels (PMPs)
• The team will proof test the concept by implementing and monitoring eight pilot units in eThekwini District, KwaZulu-Natal
22The CQUIN Learning Network
Shipping Container Features
• Air-conditioning for the temperature control of medication
• Refrigerators for the storage of thermo-labile medication
• Wash basins with running water via a reservoir if no plumbed
water available
• Impermeable work surfaces
• Lockable cupboards
• Adequate shelving for systematic storage of medication
• All openings are secured with security gates or burglar guards
• Design of the unit streamlines patient and flow
• The unit is wheel chair friendly
23The CQUIN Learning Network
Benefits
• The shipping container solution for chronic medicine pick up points is a turn key, self-sufficient , model easily adapted to urban areas
• The shipping container solution reduces over head costs, i.e. rent or lease
• In high burden areas where there is great demand for suitable building spaces the shipping container solution is ideal
• Any open space can be leveraged
• Its is scalable and relocatable
• Low initial capital outlay
• Complies with Good Pharmacy Practice
• Employs staff from local communities thereby creating jobs in the community
24The CQUIN Learning Network
Process
• Project Last Mile’s CCMDD geo-mapping and data sets provided a baseline for the project
• Based on the data analysis the following were deduced:
o high burden of disease
o high volume of CCMDD patients
• Site visits conducted in targeted areas
• Potential sites were listed and an individual pilot site was identified
• Negotiations with stakeholders included the Local Ward Councillor, eThekwini Metro Health Unit and property owner
• All parties were in agreement and eager to embark on this project
• The site was prepared, the pre-fabricated structure was installed and interior fitted
• Assessment of qualifying criteria to be a PuP was conducted and the PuP was contracted by South African National Department of Health
• Health facilities enrolling patients onto the CCMDD programme in the surrounding areas were informed of the availability and location this new PuP
25The CQUIN Learning Network
Geographic Location of PHC Facilities
26The CQUIN Learning Network
Shipping Container Solution
Growth
27The CQUIN Learning Network
53
252
977900
1784
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Nu
mb
er
of
PM
Ps
Month
Number of Patient Medicine Parcels (PMPs) Issued to Patients
Thank You
28The CQUIN Learning Network
Phil Robertsphil@projectlastmile.com+27823044595
The CQUIN Learning NetworkDifferentiated Service Delivery for Urban Populations
A CQUIN Webinar
Urban Adherence Groups in Zambia: Findings from model
implementation Mpande-Mukumbwa-Mwenechanya
BPharm, MClinPharmCentre For Infectious Disease Research In Zambia
May 2, 2018
Overview of Presentation
• Background of the Community ART Study
–Aims
• UAG Model
–Emerging Findings
–Lessons Learnt
–Recommendations
• Questions
Motivations for Differentiating Care in Zambia
• In 2013/2014, HIV care delivery in Zambia had reached stasis as
a decentralized and task-shifted system
–Practice norm: facility-based, ”one size fits all” approach
– Increasing numbers in care led to clinic congestion
• Individuals with diverse needs received similar services and
encountered substantial health systems barriers
• Continuous retention 2 years after ART initiation suboptimal
(58%1)
• Limited experimentation with community-based delivery and
differentiated care models
1CIDRZ, unpublished data, Better Info for Health In Zambia study
BMGF-funded CIDRZ Differentiated Care Study:
Community ART (March 2015-March 2018)
Aim 1: To rapidly assess local preferences for various elements and attributes of differentiated models and create an evaluation toolkit for use in other settings
GOVERNMENT AND COMMUNITY LEADERS
In-depth interviews
Examine policy environment & attitudes/perceptions of policy makers to differentiated care approaches
PROGRAMMERS & PROVIDERS
Focus group discussions
Examine beliefs about and needs for differentiated care models among direct users of healthcare system
ART & PRE-ART PATIENTS &
FAMILY
SurveysFocus groups discussions
Discrete choice experiments
Evaluation of acceptability of & preferences for differentiated care models & assessment of clinical, psychosocial, access needs
Aim 2: Rigorous evaluations of feasibility, effectiveness & cost-effectiveness of four differentiated care models, implemented with attention to scalability within the public sector ART program
CLIENT MANAGED GROUPS
Community Adherence Groups
(CAGs)
Stable rural patients rotate ARV pickup and
labs in groups of 6
(n= 1,073)
RCT
HEALTH CARE WORKER
MANAGED GROUPS
Urban Adherence Groups (UAGs)
Lay counselor distributes ARVs to
groups of ~30
(n= 1,097 )
RCT
IN FACILITY MANAGED MODEL
FAST-TRACK
Lay counselor rapid distribution of ARVs at clinics in Lusaka
(n= 408)
Observational
Streamlined/Rapid ART Initiation
Stable, pre-ART patients in urban
clinics
(n= 422)
Observational
Primary OutcomeRetention in care
Secondary OutcomesVirologic suppression, Cost-effectiveness,
Implementation outcomes
Eligibility Criteria for Enrolment into DSD model
• HIV-positive adolescents and adults (>14 years old)
• Last 6 month CD4 count > 200
*if last 6 month CD4 count not available, clinician at facility
determined whether patient was stable
• Not acutely ill
• For ART patients, on ART for at least 6 months
Acceptability, Appropriateness & Feasibility
• Acceptance high (99%) albeit with continuing concerns about
additional human resources needed to support the meetings
outside clinic hours
• Model- and audience-specific communication perceived as
important for successful implementation.1
• Anticipated difficulties of involuntary disclosure and stigma due to
large group size and off-hours ART provision not reported after
implementation.2
• Needs design ‘templates’ accompanied by local-level authority for
iterative adaptation for UAGs to remain responsive, effective and
sustainable.3
1Effronson ICASA 2017 2Mwamba IAS 2018 3Topp ICASA2018
UAG valued for social support and convenience
“… I can be very happy if [UAG] continue. If it comes to an end and we get back to the old system, it will be a very difficult thing. Like we have already said, the kind of jobs that we are doing, it is difficult to ask for permission. This month you have asked, then the following month you ask again, then in the end they will chase you from employment ... Let it just continue because we don’t ask for permission now. Like today Sunday, we are from church, to come here, from here we will go home. Tomorrow we will be at work.”
-FGD George Female Participant
“… This group surely should continue because it is helping us; it is easy for us to collect drugs and encourage one another”
-FGD George Female Participant
The CQUIN Learning Network 37
Preliminary Results on Effectiveness
• Group meetings were generally well-attended and in nearly 1/3
of missed meetings, patients picked ARVs in time using other
means1
• Twelve month cumulative incidence of >7 days late pharmacy
visit was lower in intervention arm
(26% vs 58%; 95% CI: 23%-30% vs 54%-62%).
• Further adjusted analyses and mixed effects regression will be
conducted for twelve month cumulative incidence of missed
pharmacy visits (defined as >7, >14, and >28 days late)
The CQUIN Learning Network 381Roy IAS 2018
Cumulative incidence of > 7 days late ARV pick-up at 12 months UAG intervention (intention to treat analysis)
[Preliminary Data]
The CQUIN Learning Network 39
Control: 0.58 (95% CI: 0.54 - 0.62)
Intervention: 0.26 (95% CI: 0.23 - 0.30)
Lessons Learnt while Implementing UAGs
Overall:
• Patients miss clinical visit because it is not part of UAG meeting
• Short expiry drugs affected meeting schedule
• Slow transitioning from standard of care to UAG (e.g., missing
visit)
Enrolment:
• Weekends more popular than weekday off hours
Meeting logistics:
• Difficulty acquiring meeting space to accommodate group size
• Difficulty acquiring secure drug storage space
• Meetings take longer than planned
Attendance:
• Rains posed a challenge to attendance and thereby drug collection
Recommendations
Patient-centeredness:
• Be flexible regarding meeting day/time and group composition (couples, adolescents, women only)
• Encourage a buddy system among group members
• Set up system for appointment reminders for patients
• Have a nurse or clinician present at UAG meeting
• Integrate dispensation of other chronic care medication
Sensitization and engagement:
• Sensitization of all key stakeholders (especially community)
Human Resources:
• HRH task-shifting
• Investment in staff training and development
• Appropriate staff scheduling or compensation arrangements for staff working over weekends or off-hours
Drug Supply:
• Adequate supply with long expiry
Lab:
• Essential labs are key to patient management
Monitoring and evaluation:
• Create appropriate community and facility tools with staff trained
Thank You
The CQUIN Learning Network 42
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